Dementia Warning Signs - The Democratization of Dementia Identification

The fact is - the general public, not “experts," are *supposed* to be able to tell when something is wrong and a person needs a formal dementia diagnostic workup.

Our US President

There are two statements I’m going to make, and they may sound contradictory – but they’re not. 

1. Dementia is not a normal part of aging. 

2. The single most salient risk factor for developing dementia is advanced age.

In terms of public awareness, I would say most people are intuitively well-aware of point #2, above. Dementia – a typically progressive condition characterized by multiple cognitive deficits (including memory, language, judgement, etc.), has multiple and important modifiable and non-modifiable risk factors, but by far, the most significant risk factor is advanced age.

Again, most of the general public is aware of this. We all intuitively know that outside of what are ordinarily quite rare genetic or acquired causes, dementia is not a disease of children. 

It is a disease overwhelmingly of older adults.

From https://qbi.uq.edu.au/dementia/dementia-risk-factors.

However, by the same token – not all old people get dementia. Even amongst the “oldest-old,” those 85 and above, the prevalence rate is somewhere between around 20% to just under 40%.

In other words, on a statistical basis, dementia is not a normal part of aging. 

However, when faced with these statistics, many in the general public say “well, given the fact dementia is so common in older people, perhaps every older adults should be screened for dementia!”

This is consistent with the logic certain US states (Illinois and Washington DC) that require additional testing for drivers after they reach a certain age, and the logic behind the idea of requiring, say, air traffic controllers to retire after the age of 65.

Dementia Diagnosis 

doctor

Let’s talk about dementia diagnosis - a professional activity.

Diagnosing dementia takes specific education, training, and experience to do it – and is typically only considered the purview of licensed clinical psychologists (with requisite training and experience) and physicians. 

It requires having the patient in front of you, ideally accompanied by a person who knows them well (like a spouse or family member). It typically requires access to a person’s medical records and medication list, and administration of lab tests. Often, neuroradiological exams are ordered (e.g., brain scans, like CTs or MRIs) to rule in / rule out the contribution of specific causes of neurodegenerative illness, like stroke, multiple sclerosis, or brain lesions from cancer or infection. 

A critical, and often the initial first piece in a dementia diagnostic evaluation is the use of cognitive screening tests, such as the Saint Louis University Mental Status exam (SLUMS, the administration of which you can watch a video of, above) or the Montreal Cognitive Assessment (MoCA) – which are brief, five minute exams designed to screen for the presence of significant cognitive impairment (such as what is typically seen in dementia).

The advantage of the SLUMS or the MoCA is that it’s cheap and easy to administer, and if a positive test is obtained, it provides a pretty reliable signal further diagnostic evaluation (such as with labs, brain scans, etc.) are required. 

So, you might ask, if it’s as easy as giving an older person a SLUMS or a MoCA – a cheap, five minute paper-and-pencil test to screen them for dementia, why don’t we do this for all older people? Good question. 

Should we Test All People Above a Certain Age for Dementia?  

The Veterans Healthcare System (VHA), the US Federal Agency most of us know of as “the VA,” is the most well-known arm of the US Department of Veterans Affairs – and it is the arm that provides healthcare to US veterans. 

The VHA is also the single largest integrated healthcare system in the world in terms of its resources and overall patient population it serves, and arguably the most highly managed of managed-care healthcare bureaucracies. Given the 150-billion-dollar-plus budget the VHA controls for its healthcare operations, it would seem for good reason. They have a keen interest in safeguarding these dollars, and making sure they are not expended wastefully.

In 2006, the Department of Veterans Affairs’ “Office of Patient Care Services” commissioned an interdisciplinary, interoffice committee supported by the Office of Geriatrics and Extended Care Services.

Their work culminated in the 2016 document you can read here which covers a sweepings set of topics regarding dementia treatment, education, research, and also diagnosis and identification. 

One of the questions they tackled was – is it cost-effective for primary care physicians to offer cognitive screenings like the SLUMS or MoCA indiscriminately to all community-dwelling older adults (say, 75 or older)? 

It may surprise many of you – but the answer is no.

“Clinicians should use dementia warning signs to prompt assessment of cognitive function. If warning signs are present, patients should be evaluated further” - Page 2

For sure, in many cases, mass testing of all older adults routinely using brief dementia screens may end up catching more cases of, say, Alzheimer’s Disease early, and likely allow for more timely introduction of the modestly-effective medications available (like Namenda or Aricept), or allow patients and families to make vital future plans when the patient’s cognitive faculties are still relatively intact and they are still independent (e.g., such as completing a will, or firming up plans for how to be cared for at home).  

However, what the VA Steering Committee found is that in many more cases, indiscriminate cognitive testing results in a large number of false positives that end up triggering a cascade of diagnostic followup tests that result in significant amounts of money spent chasing for confirmation of disease that does not actually exist.

Worse – the follow-up diagnostic tests triggered by the erroneously-positive dementia screening results may themselves generate incidental findings, all of this translates to potentially wasted money, resources, and often considerable psychological stress to patients and families that could have been avoided had a test not been administered in the first place.

In other words, we need some other way to identify potential cases of dementia early, so that the person can be sent to a doctor for a proper (and, as we noted, sometimes expensive) workup.

Using Dementia Warning Signs to Decide when to Administer Diagnostic Screening & Testing

From the Alzheimer’s Association - one of the most venerable of caregiver support & patient advocacy organizations out there.

If you follow me on X, you would know by now this is something I’ve been hammering for awhile now. For many years (at least since the 90s IIRC), major caregiver advocacy organizations such as the Alzheimer’s Association have pushed the idea of Dementia Warning Signs, which are depicted in the infographic, above. They are as follows:

1. Significant memory loss: Forgetting important dates, relying on external memory aids, or repeated questioning (very familiar to caregivers). Has to disrupt daily life.

2. Problem-solving or so-called “executive functioning” deficits: Evidenced by difficulty following what used to be a familiar recipe - or keeping track of monthly bills and finances.

3. Difficulty completing familiar tasks: This often shows up as trouble driving to a familiar location (and getting lost), or remembering the rules of a favorite game.

4. Confusion with time or place: Disorientation - person loses track of dates, seasons, or the passage of time. Gets lost in familiar surroundings.

5. Trouble understanding visual images and spatial relationships: So-called “visuospatial deficits.” The person has difficulties in reading, judging distance, or determining colors or contrast.

6. New problems with words in speaking or writing: Trouble following or joining a conversation, repeating oneself, or struggling to find the right word.

7. Misplacing things and losing the ability to retrace steps: Often this shows up when grandma or grandpa starts sticking things like socks in the oven, or, say, stuffing laundry in the food pantry. They may being unable to retrace steps to find them. They start accusing others of stealing.

8. Decreased or poor judgment: Making unwise decisions, such as giving away large sums of money, or neglecting personal hygiene. Often this shows up as uncharacteristically falling victim to financial scams, or making significant financial errors that are only discovered after the fact (scary!).

9. Withdrawal from work or social activities: Shows up as losing interest in hobbies they formally enjoyed. They may withdraw from socializing, or participating in activities once enjoyed.

10. Changes in mood and personality: They become much more and uncharacteristically upset, confused, suspicious, fearful, or depressed.

GeroDoc Getting Frustrated

It’s been like a modern-day version of “The Emperor’s New Clothes.” Everyone is pretending. It’s bizarre.

So, I kind of had it the other day on X (which is where I do the majority of my venting) after Biden had yet another public appearance where he seemed to be hallucinating dead people as being alive. In this case, Joe Biden was at a press event and spoke of meeting with French President Francois Mitterand at a G7 event in 2021.

The only problem being was in 2021 - Mitterand had been dead for over 20 years.

This wasn’t his only major lapse just this week - at another event (it may have even been the same day) - Biden apparently referred twice that he met with former German chancellor Helmut Kohl instead of former Chancellor Angela Merkel at a 2021 event. Helmut Kohl, like Mitterand - is dead.

This, of course, harkens back to the infamous episode (which I noted in an article just last week) where Biden appeared to hallucinate a dead congresswoman as being alive at a press event back in late 2022.

But - This Does Not Mean Joe Biden has Dementia

Let’s be totally fair. And I’m serious here - identifying these examples, as many of them as we may want to generate - are not the same as diagnosing dementia.

They *may* be examples of these so-called “warning signs,” but that’s not for me to say as some anonymous expert, right?

Any one of these examples could be explained away - Biden could be tired. He has a long-cited history of having a “stutter” (which is used to explain away his frequent episodes of incoherence in public). He could be having other medical problems that are *not* dementia - for example, he could have a waxing and waning delirium, or some kind of other issue.

The point is - I think it’s fair for someone to say that at a certain point, it’s irresponsible to not have our US President, the man with the “nuclear football,” our Commander-in-Chief, be given a standard dementia workup given the what-seems-to-be-increasing episodes of confused, incoherent, and otherwise concerning behavior in public.

To date - Biden’s press people and his White House physician have never released any evidence that he has had such an examination. No SLUMS, no MoCA, nothing. In fact, get a load of this:

For the record, Donald Trump had a MoCA test in 2018.

He reportedly scored a 30 out of 30. Make whatever of that you wish.